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Drew T, Radwan MA, McCaul CL. In the Nick of Time-Emergency Front-of-Neck Airway Access. Int Anesthesiol Clin 2024; 62:101-114. [PMID: 39233576 DOI: 10.1097/aia.0000000000000456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2024]
Abstract
Emergency front-of-neck access refers to all techniques that deliver oxygen into the airway lumen through the anterior neck structures and encompasses access both through the cricothyroid membrane and the tracheal wall. There has yet to be a universal agreement regarding the preferred technique. A surgical incision is currently the most common approach in prehospital and in-hospital care. This review intends to review and summarize the existing clinical, basic science, and societal guidelines for eFONA.
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Affiliation(s)
- Thomas Drew
- Department of Anesthesiology, The Rotunda Hospital, Dublin, Ireland
- Department of Anesthesiology, Beaumont Hospital, Dublin, Ireland
- RCSI University of Medicine and Health Sciences
| | - Mohamad Atef Radwan
- Department of Anesthesiology, The Rotunda Hospital, Dublin, Ireland
- RCSI University of Medicine and Health Sciences
| | - Conan Liam McCaul
- Department of Anesthesiology, The Rotunda Hospital, Dublin, Ireland
- Department of Anaesthesiology, Mater Misericordiae Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Ireland
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2
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Xu R, Li Z, Jiang X, Zhang W, Xu Y, Zhang Y, Zhu L, Wei H, Shi H, Wang X. Effect of supraglottic jet oxygenation and ventilation on hypoxemia in patients undergoing endoscopic surgery with sedation: A meta-analysis of randomized controlled trials. J Clin Anesth 2024; 97:111559. [PMID: 39047532 DOI: 10.1016/j.jclinane.2024.111559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 07/10/2024] [Accepted: 07/17/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND Nasal cannulas and face masks are common oxygenation tools used in conventional oxygen therapy for patients undergoing endoscopic surgery with sedation. However, as a novel supraglottic ventilation technique, the application of supraglottic jet oxygenation and ventilation (SJOV) in endoscopic surgery has not been well established. METHOD We searched six electronic databases from inception to January 16, 2024, to assess the oxygenation/ventilation efficacy and side effects of the of SJOV in endoscopic surgery. The primary outcome was the incidence of hypoxemia. The secondary outcomes were the incidence of respiratory depression and adverse effects (nasal bleeding, sore throat, and dry mouth). RESULTS Nine trials involving 2017 patients were included. The results demonstrated that the incidence of hypoxemia was lower in the SJOV group compared with the conventional oxygen therapy (COT) group [9 trails; 2017 patients; risk ratio (RR) = 0.18; 95% confidence interval (CI), (0.11-0.28)]. Subgroup analyses showed that SJOV reduced the incidence of hypoxemia in the high-risk group but had no effect on the low-risk group. The incidence of respiratory depression is lower in SJOV than in COT, but has increased side effects such as dry mouth. There was no statistically significant difference in nose bleeding or sore throat between the two groups. CONCLUSION Compared with the COT, the SJOV decreased the incidence of hypoxemia in high-risk patients during endoscopic surgery with sedation. There was an increased risk of dry mouth, but not of nose bleeding or sore throat, during endoscopic surgery under sedation.
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Affiliation(s)
- Rukun Xu
- Department of Anesthesiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Zixuan Li
- Department of Anesthesiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Xue Jiang
- Department of Anesthesiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Wenwen Zhang
- Department of Anesthesiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yajie Xu
- Department of Anesthesiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yong Zhang
- Department of Anesthesiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Lili Zhu
- Department of Anesthesiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Huafeng Wei
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Hongwei Shi
- Department of Anesthesiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China.
| | - Xiaoliang Wang
- Department of Anesthesiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China.
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3
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Heard AM, Lacquiere DA, Gordon HL, Douglas SG, Avis HJ. A case series of the Royal Perth Hospital cannula-first approach in the 'can't intubate, can't oxygenate' scenario. Anaesth Intensive Care 2024; 52:159-167. [PMID: 38546511 DOI: 10.1177/0310057x231214548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
At the Royal Perth Hospital, we have been developing and teaching a can't intubate, can't oxygenate (CICO) rescue algorithm for over 19 years, based on live animal simulation. The algorithm involves a 'cannula-first' approach, with jet oxygenation and progression to scalpel techniques if required in a stepwise fashion. There is little reported experience of this approach to the CICO scenario in humans. We present eight cases in which a cannula-first Royal Perth Hospital approach was successfully implemented during an airway crisis. We recommend that institutions teach and practice this approach; we believe it is effective, safe and minimally invasive when undertaken by clinicians who have been trained in it and have immediate access to the requisite equipment. The equipment is low cost, comprising a 14G Insyte cannula, saline, 5 ml syringe and a Rapid-O2. Training can be provided using low-fidelity manikins or part-task trainers.
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Affiliation(s)
- Andrew Mb Heard
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, Australia
| | - David A Lacquiere
- South Australian Ambulance Service MedSTAR, Adelaide, Australia
- Pulse Anaesthetics, Adelaide, Australia
| | - Helen L Gordon
- Anaesthetic Department, Dorset County Hospital, Dorchester, UK
| | - Scott G Douglas
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, Australia
| | - Hans J Avis
- Department of Anaesthesia, Amsterdam University Medical Center, Amsterdam, The Netherlands
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4
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Wei H. Advancement of supraglottic jet oxygenation and ventilation technique. Indian J Anaesth 2024; 68:409-411. [PMID: 38764953 PMCID: PMC11100645 DOI: 10.4103/ija.ija_330_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 03/26/2024] [Accepted: 03/26/2024] [Indexed: 05/21/2024] Open
Affiliation(s)
- Huafeng Wei
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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5
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Maurya I, Ahmed SM, Garg R. Simulation in airway management teaching and training. Indian J Anaesth 2024; 68:52-57. [PMID: 38406347 PMCID: PMC10893796 DOI: 10.4103/ija.ija_1234_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 12/25/2023] [Accepted: 12/31/2023] [Indexed: 02/27/2024] Open
Abstract
There is a gradual shift in training and teaching methods in the medical field. We are slowly moving from the traditional model and adopting active learning methods like simulation-based training. Airway management is an essential clinical skill for any anaesthesiologist, and a trained anaesthesiologist must perform quick and definitive airway management using various techniques. Airway simulations have been used for the past few decades. It ensures active involvement, upgrading the trainees' airway management knowledge and skills, including basic airway skills, invasive procedures, and difficult clinical scenarios. Trainees also learn non-technical skills such as communication, teamwork, and coordination. A wide range of airway simulators are available. However, texture surface characteristics vary from one type to another. The simulation-based airway management training requires availability, understanding, faculty development, and a structured curriculum for effective delivery. This article explored the available evidence on simulation-based airway management teaching and training.
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Affiliation(s)
- Indubala Maurya
- Department of Anaesthesiology, Kalyan Singh Super Specialty Cancer Institute, Lucknow, Uttar Pradesh, India
| | - Syed M. Ahmed
- Department of Anaesthesiology and Critical Care, Jawaharlal Nehru Medical College Hospital, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
| | - Rakesh Garg
- Department of Onco-Anaesthesia, Pain and Palliative Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
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6
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Huang AE, Camiré D, Hwang PH, Nekhendzy V. Difficult Tracheal Intubation and Airway Outcomes after Radiation for Nasopharyngeal Carcinoma. Laryngoscope 2024; 134:120-126. [PMID: 37249176 DOI: 10.1002/lary.30767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/07/2023] [Accepted: 05/09/2023] [Indexed: 05/31/2023]
Abstract
OBJECTIVE The aim of the study was to characterize the incidence and management of difficult tracheal intubations (DTIs) in nasopharyngeal carcinoma (NPC) after primary radiation therapy (RT). METHODS The study was a retrospective review of airway assessment and outcomes in post-RT NPC patients. Primary analysis was performed on patients who underwent post-RT procedures, who were split into non-DTI and DTI groups. Patients were classified as DTI if they (i) required >1 attempt to intubate, (ii) failed to be intubated, or (iii) experienced complications attributed to airway management. Secondary analysis was performed between patients who underwent post-RT procedures (procedure group) and those who did not (control group). RESULTS One-hundred and fifty patients were included, and 71.3% underwent post-RT procedures, with no differences in characteristics between the procedure and control groups. One-hundred and fifty procedures were identified, and 28.0% were categorized as DTI. There was no difference in patient characteristics or airway assessment measures between DTI and non-DTI groups. Regression analysis revealed concurrent cervical mobility restriction, and trismus increased DTI incidence by 7.1-fold (p = 0.011). Being non-White was an independent predictor of DTI. The incidence of high-grade intraoperative laryngoscopic view was lower in the non-DTI compared to the DTI group (20.4% vs. 64.3%, p < 0.0001). Failure to intubate occurred in 2.0% of cases, and 6.0% cases had perioperative complications. Based on preoperative assessment, sensitivity of predicting DTI was 54.8% and specificity was 63.9%. CONCLUSION NPC patients frequently undergo post-RT procedures requiring complex airway management. Rates of DTI and failed intubation are significantly higher than those in the general surgical population, and the ability to predict DTI with standard preoperative airway measures is poor. LEVEL OF EVIDENCE 4 Laryngoscope, 134:120-126, 2024.
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Affiliation(s)
- Alice E Huang
- Stanford Hospital, Department of Otolaryngology-Head & Neck Surgery, Stanford University, Stanford, California, USA
| | - Daenis Camiré
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California, USA
| | - Peter H Hwang
- Stanford Hospital, Department of Otolaryngology-Head & Neck Surgery, Stanford University, Stanford, California, USA
| | - Vladimir Nekhendzy
- Stanford Hospital, Department of Otolaryngology-Head & Neck Surgery, Stanford University, Stanford, California, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California, USA
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7
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Vannucci J, Capozzi R, Vinci D, Ceccarelli S, Potenza R, Scarnecchia E, Spinosa E, Romito M, Napolitano AG, Puma F. Concomitant Intubation with Minimal Cuffed Tube and Rigid Bronchoscopy for Severe Tracheo-Carinal Obstruction. J Clin Med 2023; 12:5258. [PMID: 37629301 PMCID: PMC10455797 DOI: 10.3390/jcm12165258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 07/28/2023] [Accepted: 08/10/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Our aim was to report on the use of an innovative technique for airway management utilizing a small diameter, short-cuffed, long orotracheal tube for assisting operative rigid bronchoscopy in critical airway obstruction. METHODS We retrospectively reviewed the clinical data of 36 patients with life-threatening critical airway stenosis submitted for rigid bronchoscopy between January 2008 and July 2021. The supporting ventilatory tube, part of the Translaryngeal Tracheostomy KIT (Fantoni method), was utilized in tandem with the rigid bronchoscope during endoscopic airway reopening. RESULTS Indications for collateral intubation were either tumors of the trachea with near-total airway obstruction (13), or tumors of the main carina with total obstruction of one main bronchus and possible contralateral involvement (23). Preliminary dilation was necessary before tube placement in only 2/13 patients with tracheal-obstructing tumors (15.4%). No postoperative complications were reported. There was one case of an intraoperative cuff tear, with no further technical problems. CONCLUSIONS In our experience, this innovative method proved to be safe, allowing for continuous airway control. It enabled anesthesia inhalation, use of neuromuscular blockage and reliable end-tidal CO2 monitoring, along with protection of the distal airway from blood flooding. The shorter time of the procedure was due to the lack of need for pauses to ventilate the patient.
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Affiliation(s)
- Jacopo Vannucci
- Department of Thoracic Surgery and Lung Transplantation, University of Rome Sapienza, Policlinico Umberto I, 00161 Rome, Italy
| | - Rosanna Capozzi
- Department of Thoracic Surgery, University of Perugia Medical School, Ospedale Santa Maria della Misericordia, 06134 Perugia, Italy; (R.C.); (D.V.); (S.C.); (R.P.); (E.S.); (E.S.); (M.R.); (A.G.N.); (F.P.)
| | - Damiano Vinci
- Department of Thoracic Surgery, University of Perugia Medical School, Ospedale Santa Maria della Misericordia, 06134 Perugia, Italy; (R.C.); (D.V.); (S.C.); (R.P.); (E.S.); (E.S.); (M.R.); (A.G.N.); (F.P.)
| | - Silvia Ceccarelli
- Department of Thoracic Surgery, University of Perugia Medical School, Ospedale Santa Maria della Misericordia, 06134 Perugia, Italy; (R.C.); (D.V.); (S.C.); (R.P.); (E.S.); (E.S.); (M.R.); (A.G.N.); (F.P.)
| | - Rossella Potenza
- Department of Thoracic Surgery, University of Perugia Medical School, Ospedale Santa Maria della Misericordia, 06134 Perugia, Italy; (R.C.); (D.V.); (S.C.); (R.P.); (E.S.); (E.S.); (M.R.); (A.G.N.); (F.P.)
| | - Elisa Scarnecchia
- Department of Thoracic Surgery, University of Perugia Medical School, Ospedale Santa Maria della Misericordia, 06134 Perugia, Italy; (R.C.); (D.V.); (S.C.); (R.P.); (E.S.); (E.S.); (M.R.); (A.G.N.); (F.P.)
| | - Emilio Spinosa
- Department of Thoracic Surgery, University of Perugia Medical School, Ospedale Santa Maria della Misericordia, 06134 Perugia, Italy; (R.C.); (D.V.); (S.C.); (R.P.); (E.S.); (E.S.); (M.R.); (A.G.N.); (F.P.)
| | - Mara Romito
- Department of Thoracic Surgery, University of Perugia Medical School, Ospedale Santa Maria della Misericordia, 06134 Perugia, Italy; (R.C.); (D.V.); (S.C.); (R.P.); (E.S.); (E.S.); (M.R.); (A.G.N.); (F.P.)
| | - Antonio Giulio Napolitano
- Department of Thoracic Surgery, University of Perugia Medical School, Ospedale Santa Maria della Misericordia, 06134 Perugia, Italy; (R.C.); (D.V.); (S.C.); (R.P.); (E.S.); (E.S.); (M.R.); (A.G.N.); (F.P.)
| | - Francesco Puma
- Department of Thoracic Surgery, University of Perugia Medical School, Ospedale Santa Maria della Misericordia, 06134 Perugia, Italy; (R.C.); (D.V.); (S.C.); (R.P.); (E.S.); (E.S.); (M.R.); (A.G.N.); (F.P.)
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8
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Marshall SD. Human error doesn't exist in isolation: it's now time for a deeper understanding of human factors in anaesthesia. Anaesthesia 2023; 78:407-410. [PMID: 36708589 DOI: 10.1111/anae.15978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2023] [Indexed: 01/30/2023]
Affiliation(s)
- S D Marshall
- Department of Critical Care, University of Melbourne, Australia.,Department of Anaesthesia and Peri-operative Medicine, Monash University, Melbourne, Australia
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9
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Nassif D, O'Donnell R. Transtracheal jet ventilation. ANAESTHESIA & INTENSIVE CARE MEDICINE 2023. [DOI: 10.1016/j.mpaic.2022.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
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10
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Schmucker Agudelo E, Farré Pinilla M, Andreu Riobello E, Franco Castanys T, Villaverde Castillo I, Monclus Diaz E, Aragonés Panadés N, Muñoz Luz A. An update in paediatric airway management. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2022; 69:472-486. [PMID: 36096882 DOI: 10.1016/j.redare.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 05/25/2021] [Indexed: 06/15/2023]
Affiliation(s)
- E Schmucker Agudelo
- Hospital Universitario Vall d'Hebrón, Área Materno Infantil, Barcelona, Spain.
| | | | - E Andreu Riobello
- Hospital Universitario Vall d'Hebrón, Área Materno Infantil, Barcelona, Spain
| | | | | | | | | | - A Muñoz Luz
- Hospital Universitario Dr. Josep Trueta, Girona, Spain
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11
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Endlich Y, Hore PJ, Baker PA, Beckmann LA, Bradley WP, Chan KLE, Chapman GA, Jephcott CGA, Kruger PS, Newton A, Roessler P. Updated guideline on equipment to manage difficult airways: Australian and New Zealand College of Anaesthetists. Anaesth Intensive Care 2022; 50:430-446. [PMID: 35722809 DOI: 10.1177/0310057x221082664] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The Australian and New Zealand College of Anaesthetists (ANZCA) recently reviewed and updated the guideline on equipment to manage a difficult airway. An ANZCA-established document development group, which included representatives from the Australasian College for Emergency Medicine and the College of Intensive Care Medicine of Australia and New Zealand, performed the review, which is based on expert consensus, an extensive literature review, and bi-nationwide consultation. The guideline (PG56(A) 2021, https://www.anzca.edu.au/getattachment/02fe1a4c-14f0-4ad1-8337-c281d26bfa17/PS56-Guideline-on-equipment-to-manage-difficult-airways) is accompanied by a detailed background paper (PG56(A)BP 2021, https://www.anzca.edu.au/getattachment/9ef4cd97-2f02-47fe-a63a-9f74fa7c68ac/PG56(A)BP-Guideline-on-equipment-to-manage-difficult-airways-Background-Paper), from which the current recommendations are reproduced on behalf of, and with the permission of, ANZCA. The updated 2021 guideline replaces the 2012 version and aims to provide an updated, objective, informed, transparent, and evidence-based review of equipment to manage difficult airways.
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Affiliation(s)
- Yasmin Endlich
- Department of Anaesthesia and Acute Pain Medicine, Royal Adelaide Hospital, Adelaide, Australia.,Department of Paediatric Anaesthesia, Women's and Children's Hospital, North Adelaide, Australia.,Faculty of Anaesthesia, University of Adelaide, Adelaide, Australia
| | - Phillipa J Hore
- Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Melbourne, Australia
| | - Paul A Baker
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand.,Department of Anaesthesia, Starship Children's Hospital, Auckland, New Zealand
| | - Linda A Beckmann
- Department of Anaesthesia and Acute Pain Medicine, Royal Brisbane and Women's Hospital, Herston, Australia
| | - William P Bradley
- Department of Anaesthesia and Perioperative Medicine, The Alfred, Melbourne, Australia.,Faculty of Anaesthesia, Monash University, Melbourne, Australia
| | - Kah L E Chan
- Department of Anaesthesia and Acute Pain Medicine, Royal Brisbane and Women's Hospital, Herston, Australia
| | - Gordon A Chapman
- Department of Anaesthesia, Royal Perth Hospital, Perth, Australia.,Faculty of Anaesthesia, University of Western Australia, Perth, Australia
| | | | - Peter S Kruger
- Department of Intensive Care Medicine, Princess Alexandra Hospital, Brisbane, Australia
| | - Alastair Newton
- Department of Emergency Medicine, The Prince Charles Hospital, Brisbane, Australia.,Retrieval Services Queensland, Brisbane, Australia
| | - Peter Roessler
- Safety and Advocacy Unit, Australian and New Zealand College of Anaesthetists, Melbourne, Australia
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12
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Kukuev E, Belugin E, Willner D, Ronen O. Parameters of high-frequency jet ventilation using a mechanical lung model. J Med Eng Technol 2022; 46:617-623. [PMID: 35674712 DOI: 10.1080/03091902.2022.2081370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
High frequency jet ventilationis a mechanical lung ventilation method which uses a relatively high flow usually through an open system. This work examined the effect of high-frequency jet ventilation on respiratory parameters of an intubated patient simulated using a high-frequency jet ventilator attached to a ventilation monitor for measurements of ventilation parameters. The series of experiments altered specific parameters each time (respiratory rate, inspiratory-expiratory (I:E) ratio, and inspiratory pressure), under different lung compliances. A reduction of minute ventilation was observed alongside a rise in respiratory rate, with low airway pressures over the entire range of lung compliances. In addition, an I:E ratio of 2:1 to 1:1; and the tidal and minute volumes were directly related to the inspiratory pressure over all compliance settings. To conclude, the respiratory mechanics in high-frequency jet ventilation are very different from those of conventional rate ventilation in a lung model. Further studies on patients and/or a biological model are needed to investigate pCO2 and end-tidal carbon-dioxide during high-frequency jet ventilation.
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Affiliation(s)
- Evgeni Kukuev
- Departments of Anaesthesiology, Galilee Medical Centre affiliated with Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Evgeny Belugin
- Departments of Anaesthesiology, Galilee Medical Centre affiliated with Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Dafna Willner
- Departments of Anaesthesiology, Galilee Medical Centre affiliated with Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Ohad Ronen
- Departments of Otolaryngology - Head and Neck Surgery, Galilee Medical Centre affiliated with Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
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13
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Wycherley AS, Debenham EM, O'Loughlin E, Anderson JR, Syed FR, Raisis AL. Cannula cricothyroidotomy in the impalpable neck: An observational study of simulated 'can't intubate, can't oxygenate' scenarios by teams following a cannula-first algorithm in live anaesthetised pigs. Anaesth Intensive Care 2022; 50:368-379. [PMID: 35549915 DOI: 10.1177/0310057x211066927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Live animal models can be used to train anaesthetists to perform emergency front-of-neck-access. Cannula cricothyroidotomy success reported in previous wet lab studies contradicts human clinical data. This prospective, observational study reports success of a cannula-first 'can't intubate, can't oxygenate' algorithm for impalpable anatomy during high fidelity team simulations using live, anaesthetised pigs.Forty-two trained anaesthesia teams were instructed to follow the Royal Perth Hospital can't intubate, can't oxygenate algorithm to re-oxygenate a desaturating pig with impalpable neck anatomy (mean (standard deviation, SD) 16.2 (3.5) kg); mean (SD) tracheal internal diameter 11 (1.4) mm. Teams were informed that failure would prompt veterinary-led euthanasia.All teams performed percutaneous cannula cricothyroidotomy as the initial technique, with a median (interquartile range, IQR (range)) start time of 42 (35-50 (24-93)) s. First-pass percutaneous cannula success was 29% to both insufflate tracheal oxygen and re-oxygenate. Insufflation success improved with repeated percutaneous attempts (up to three), but prolonged hypoxia time increasingly necessitated euthanasia (insufflation 57%; re-oxygenation 48%). First, second and third percutaneous attempts achieved insufflation at median (IQR (range)) 74 (64-91 (46-110)) s, 111 (95-136 (79-150)) s and 141 (127-159 (122-179)) s, respectively. Eighteen teams failed with percutaneous cannulae and performed scalpel techniques, predominantly dissection cannulation (n = 17) which achieved insufflation in all cases (insufflation 100%; re-oxygenation 47%). Scalpel attempts were started at median (IQR (range)) 142 (133-218 (97-293)) s and achieved insufflation at 232 (205-303 (152-344)) s.While percutaneous cannula cricothyroidotomy could rapidly re-oxygenate, the success rate was low and teams repeated attempts beyond the recommended 60 s time frame, delaying transition to the more successful dissection cannula technique. We recommend this 'cannula-first' can't intubate, can't oxygenate algorithm adopts a 'single best effort' strategy for percutaneous cannula, with failure prompting a scalpel technique.
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Affiliation(s)
- Alexander S Wycherley
- Department of Anaesthesia, Pain and Perioperative Medicine, Fiona Stanley and Fremantle Hospitals, Murdoch, Australia.,School of Veterinary and Life Sciences, Murdoch University, Murdoch, Australia
| | - Edward M Debenham
- Department of Anaesthesia, Pain and Perioperative Medicine, Fiona Stanley and Fremantle Hospitals, Murdoch, Australia.,School of Veterinary and Life Sciences, Murdoch University, Murdoch, Australia
| | - Edmond O'Loughlin
- Department of Anaesthesia, Pain and Perioperative Medicine, Fiona Stanley and Fremantle Hospitals, Murdoch, Australia
| | - James R Anderson
- Department of Anaesthesia, Pain and Perioperative Medicine, Fiona Stanley and Fremantle Hospitals, Murdoch, Australia
| | - Faraz R Syed
- Department of Anaesthesia, Pain and Perioperative Medicine, Fiona Stanley and Fremantle Hospitals, Murdoch, Australia
| | - Anthea L Raisis
- School of Veterinary and Life Sciences, Murdoch University, Murdoch, Australia
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14
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[Airway management for surgical tracheotomy-a common problem with unusual presentation]. Anaesthesist 2022; 71:706-708. [PMID: 35499613 PMCID: PMC9427878 DOI: 10.1007/s00101-022-01121-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/28/2022] [Accepted: 04/06/2022] [Indexed: 11/15/2022]
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15
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Zhang J, Ong S, Toh H, Chew M, Ang H, Goh S. Success and Time to Oxygen Delivery for Scalpel-Finger-Cannula and Scalpel-Finger-Bougie Front-of-Neck Access: A Randomized Crossover Study With a Simulated "Can't Intubate, Can't Oxygenate" Scenario in a Manikin Model With Impalpable Neck Anatomy. Anesth Analg 2022; 135:376-384. [PMID: 35245225 DOI: 10.1213/ane.0000000000005969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Emergency front-of-neck access (FONA) is particularly challenging with impalpable neck anatomy. We compared 2 techniques that are based on a vertical midline neck incision, followed by finger dissection and then either a cannula or scalpel puncture to the cricothyroid membrane. METHODS A manikin simulation scenario of impalpable neck anatomy and bleeding was created. Sixty-five anesthesiologists undergoing cricothyrotomy training performed scalpel-finger-cannula (SFC) and scalpel-finger-bougie (SFB) cricothyrotomy in random order. Primary outcomes were time to oxygen delivery and first-attempt success; data were analyzed using multilevel mixed-effects models. RESULTS SFC was associated with a shorter time to oxygen delivery on univariate (median time difference, -61.5 s; 95% confidence interval [CI], -84.7 to -38.3; P < .001) and multivariable (mean time difference, -62.1 s; 95% CI, -83.2 to -41.0; P < .001) analyses. Higher first-attempt success was reported with SFC than SFB (47 of 65 [72.3%] vs 18 of 65 [27.7%]). Participants also had higher odds at achieving first-attempt success with SFC than SFB (odds ratio [OR], 10.7; 95% CI, 3.3-35.0; P < .001). Successful delivery of oxygen after the "can't intubate, can't oxygenate" (CICO) declaration within 3 attempts and 180 seconds was higher (84.6% vs 63.1%) and more likely with SFC (OR, 5.59; 95% CI, 1.7-18.9; P = .006). Analyzing successful cases only, SFC achieved a shorter time to oxygen delivery (mean time difference, -24.9 s; 95% CI, -37.8 to -12.0; P < .001), but a longer time to cuffed tube insertion (mean time difference, +56.0 s; 95% CI, 39.0-73.0; P < .001). After simulation training, most participants preferred SFC in patients with impalpable neck anatomy (75.3% vs 24.6%). CONCLUSIONS In a manikin simulation of impalpable neck anatomy and bleeding, the SFC approach demonstrated superior performance in oxygen delivery and was also the preferred technique of the majority of study participants. Our study findings support the use of a cannula-based FONA technique for achieving oxygenation in a CICO situation, with the prerequisite that appropriate training and equipment are available.
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Affiliation(s)
- Jinbin Zhang
- From the Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore
| | - Shimin Ong
- From the Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore
| | - Han Toh
- Department of Anaesthesia, Woodlands Health, Singapore
| | - Meifang Chew
- From the Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore
| | - Hope Ang
- From the Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore
| | - Stacey Goh
- From the Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore
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Emergency Subglottic Airway Training and Assessment of Skills Retention of Attending Anesthesiologists With Simulation Mastery-Based Learning. Anesth Analg 2022; 135:143-151. [PMID: 35147576 DOI: 10.1213/ane.0000000000005928] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Although included within the American Society of Anesthesiologists difficult airway algorithm, the use of "invasive airway access" is rarely needed clinically. In conjunction with highly associated morbidity and liability risks, it is a challenge for the average anesthesiologist to develop and maintain competency. The advancement of high-fidelity simulators allows for practice of rarely encountered clinical scenarios, specifically those requiring invasive subglottic airway techniques. METHODS Sixty board-certified academic anesthesiologists were enrolled and trained in dyads in a simulation-based, mastery-based learning (MBL) course directed at 2 emergency airway subglottic techniques: transtracheal jet ventilation (TTJV) and bougie cricothyrotomy (BC). Performance metrics included: pretest, posttest, specific skill step error tracking, and 15-month period retest. All were pretested and trained once on the Melker cricothyrotomy (MC) kit. All pretest assessment, training, posttesting, and 15-month retesting were performed by a single expert clinical and educational airway management faculty member. RESULTS Initial testing showed a success rate of 14.8% for TTJV, 19.7% for BC, and 25% for MC. After mastery-based practice, all anesthesiologists achieved successful invasive airway placement with TTJV, BC, and MC. Repeated performance of each skill improved speed with zero safety breaches. BC was noted to be the fastest performed technique. Fifteen months later, retesting showed that 80.4% and 82.6% performed successful airway securement for TTJV and BC, respectively. For safety, average placement time and costs, MC was discarded after initial training results. CONCLUSIONS We discovered that only ~20% of practicing anesthesiologists were able to successfully place an invasive airway in a simulated life or death clinical setting. Using mobile simulation (training performed in department conference room) during a 2.5-hour session using mastery-based training pedagogy, we increased our success rate of invasive airway placement to 100%, while also increasing the successful speed to ventilation (TTJV, 32 seconds average; BC, 29 seconds average). Finally, we determined that there was a 15-month 80% retention rate of the airway skills learned, indicating that skills last at least a year before retraining is required using this training methodology.
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17
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Baker PA, von Ungern-Sternberg BS. Primum non nocere ("first do no harm") with oxygen therapy. Paediatr Anaesth 2022; 32:101-102. [PMID: 35045214 DOI: 10.1111/pan.14367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/02/2021] [Accepted: 12/05/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Paul A Baker
- Department of Anesthesiology, University of Auckland, Auckland, New Zealand.,Starship Children's Hospital, Auckland, New Zealand
| | - Britta S von Ungern-Sternberg
- Division of Emergency Medicine, Anesthesia and Pain Medicine, Medical School, The University of Western Australia, Perth, WA, Australia.,Department of Anesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia.,Perioperative Medicine Team, Telethon Kid's Institute, Perth, WA, Australia
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18
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Chauhan SK, Monaghan M, McCaul CL. Evaluation of a novel emergency front of neck access device in a benchtop model of obesity. Ir J Med Sci 2022; 191:413-420. [PMID: 33656661 DOI: 10.1007/s11845-021-02530-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 01/26/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Emergency front of neck access (eFONA) is a critical step in oxygenation in cases of unrelieved airway obstruction. Multiple techniques are used in clinical practice without agreement regarding the optimal approach. We evaluated a novel device, the Cric-Guide (CG), a channelled bougie introducer that enters the airway in a single action and compared it with a scalpel-bougie-tube (SBT) technique in laboratory benchtop model. METHODS Seven anaesthesiologists attempted eFONA on both obese and non-obese models using both techniques in randomized order on an excised porcine trachea with an intact larynx with variable subcutaneous tissue depth. The primary outcome was successful tracheal cannulation. Secondary outcomes included false passage rate, time and tissue injury. RESULTS Anaesthesiologists performed 4 cricothyroidotomies on each model with each device. The CG was more successful in airway cannulation (47/56 [89.4%] vs. 33/56 [58.9%], P = 0.007). This difference was observed in the obese model only. The CG was associated with fewer false passages than the standard technique in the obese model (8/56 [14.3%] vs. 23/56 [41.1%], P = 0.006). There were no significant differences in time to completion or injury patterns between the techniques in the obese model, but the SBT was faster in the non-obese model. There was no difference in the proportion of specimens injured. CONCLUSION The Cric-Guide device was more successful than the standard SBT technique in airway cannulation in an obese neck model and with equivalent frequency and distribution of injury but performed equivalently in the non-obese model.
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Affiliation(s)
| | | | - Conan L McCaul
- The Rotunda Hospital, Dublin, Ireland.
- The Rotunda Hospital, Mater Misericordiae University Hospital, Dublin, Ireland.
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19
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de Wolf M, Enk D, Jagannathan N. Ventilation through small-bore airways in children by implementing active expiration. Paediatr Anaesth 2022; 32:312-320. [PMID: 34902197 PMCID: PMC9255377 DOI: 10.1111/pan.14379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 11/29/2021] [Accepted: 12/01/2021] [Indexed: 12/16/2022]
Abstract
Management of narrowed airways can be challenging, especially in the smallest patients. This educational review focusses on active expiration through small-bore airways with the Ventrain (Ventinova Medical, Eindhoven, The Netherlands). Manual ventilation with the Ventrain establishes inspiratory and expiratory flow control: By setting an appropriate flow, the volume of gas insufflated over time can be controlled and expiration through a small-bore airway is expedited by jet-flow generated suction, coined "expiratory ventilation assistance" (EVA). This overcomes the inherent risks of emergency jet ventilation especially in pediatric airway emergencies. Active expiration by EVA has been clinically introduced to turn a "straw in the airway" into a lifesaver allowing not only for quick and reliable reoxygenation but also adequate ventilation. As well as managing airway emergencies, ventilating through small-bore airways by applying EVA implements new options for pediatric airway management in elective interventional procedures. Safe application of EVA demands a thorough understanding of the required equipment, the principle and function of the Ventrain, technical prerequisites, clinical safety measures, and, most importantly, appropriate training.
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Affiliation(s)
- Michiel de Wolf
- Department of Anesthesiology and Pain MedicineMaastricht University Medical CenterMaastrichtThe Netherlands
| | - Dietmar Enk
- Medical FacultyUniversity of MünsterMünsterGermany
| | - Narasimhan Jagannathan
- General Academic & Clinical AnesthesiologyAnn & Robert H. Lurie Children's Hospital of ChicagoChicagoIllinoisUSA
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20
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Reardon RF, Robinson AE, Kornas R, Ho JD, Anzalone B, Carlson J, Levy M, Driver B. Prehospital Surgical Airway Management: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:96-101. [PMID: 35001821 DOI: 10.1080/10903127.2021.1995552] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Bag-valve-mask ventilation and endotracheal intubation have been the mainstay of prehospital airway management for over four decades. Recently, supraglottic device use has risen due to various factors. The combination of bag-valve-mask ventilation, endotracheal intubation, and supraglottic devices allows for successful airway management in a majority of patients. However, there exists a small portion of patients who are unable to be intubated and cannot be adequately ventilated with either a facemask or a supraglottic airway. These patients require an emergent surgical airway. A surgical airway is an important component of all airway algorithms, and in some cases may be the only viable approach; therefore, it is imperative that EMS agencies that are credentialed to manage airways have the capability to perform surgical airways when appropriate. The National Association of Emergency Medical Services Physicians (NAEMSP) recommends the following for emergency medical services (EMS) agencies that provide advanced airway management.A surgical airway is reasonable in the prehospital setting when the airway cannot be secured by less invasive means.When indicated, a surgical airway should be performed without delay.A surgical airway is not a substitute for other airway management tools and techniques. It should not be the only rescue option available.Success of an open surgical approach using a scalpel is higher than that of percutaneous Seldinger techniques or needle-jet ventilation in the emergency setting.
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21
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Coté CJ. Letter RE: Cannula insufflation device performance. Paediatr Anaesth 2021; 31:1017-1018. [PMID: 34409706 DOI: 10.1111/pan.14230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 05/26/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Charles J Coté
- Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
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22
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Grudzinski AL, Morgan A, Duggan LV. “Pick Up a Knife, Save a Life”: Emergency Front-of-Neck Airway for the Non-Surgeon Clinician. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00473-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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23
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Fennessy P, Greco E, Gelber N, Brewster DJ, Reeves JH. Emergency Front-of-Neck Airway Rescue Via the Cricothyroid Membrane: A High-Resolution Computed Tomography Study of Airway Anatomy in Adults. Anesth Analg 2021; 133:187-195. [PMID: 33989226 DOI: 10.1213/ane.0000000000005583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Emergency front-of-neck airway rescue is recommended in a can't intubate, can't oxygenate clinical scenario. Cannula cricothyroidotomy has been reported as having a high failure rate. Our primary aim was to estimate the angle of the trachea in relation to the horizontal axis in a simulated emergency front-of-neck airway rescue position. Our secondary aims were to estimate the optimal cannula angle of approach and evaluate the anatomical relationship of the cricothyroid membrane (CTM) to adjacent structures. We also assessed whether the CTM lies above or below the neck midpoint, a point equidistant from the suprasternal notch (SSN), and the chin surface landmarks. All measurements were compared between the male and female subjects. METHODS Subjects having elective computed tomography of their thorax were consented to have extension of the computed tomography to include their neck. A preliminary radiation dose and risk assessment deemed the additional radiation to be of very low risk (level IIa). Subjects were positioned supinely on the computed tomography table. Standard neck extension was achieved by placing a pillow under the scapulae and a rolled towel under the neck to simulate emergency front-of-neck airway rescue positioning. RESULTS Fifty-two subjects were included in this study: 31 men and 21 women. The mean angle of the trachea in relation to the horizontal axis was 25.5° (95% confidence interval [CI], 21.8-29.1) in men and 14.0° (95% CI, 11.5-16.5) in women. The mean minimum angles required for hypothetical cannula cricothyroidotomy for men and women were 55.2° (95% CI, 51.8-58.7) and 50.5° (95% CI, 45.4-55.6), respectively. The CTM was located lower in the neck in men compared to women. The CTM was located below the neck midpoint in 30 of 30 (100%) male subjects and 11 of 20 (55%) female subjects (P < .001). CONCLUSIONS The trachea angulates posteriorly in a simulated emergency front-of-neck airway rescue position in supine subjects and to a greater degree in men compared to women (P < .001). The minimum angle required for hypothetical cannula cricothyroidotomy was >45° in the majority (75%) of subjects studied. A steeper cannula angle of approach may be more reliable and warrants further clinical study. If airway anatomy is indistinct and performing a vertical scalpel cricothyroidotomy, consideration should be given to performing this incision lower in the neck in men compared to women.
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Affiliation(s)
- Paul Fennessy
- From the Department of Anesthesiology, Alfred Hospital, Melbourne, Victoria, Australia.,National University of Ireland, Galway, Ireland
| | | | | | - David J Brewster
- Cabrini Health, Malvern, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - John H Reeves
- From the Department of Anesthesiology, Alfred Hospital, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
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24
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McNarry AF, Asai T. New evidence to inform decisions and guidelines in difficult airway management. Br J Anaesth 2021; 126:1094-1097. [PMID: 33836852 DOI: 10.1016/j.bja.2021.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/14/2021] [Accepted: 03/03/2021] [Indexed: 12/13/2022] Open
Affiliation(s)
| | - Takashi Asai
- Department of Anesthesiology, Dokkyo Medical University Saitama Medical Centre, Koshigaya, Japan
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25
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Pertile J, Smith B, Mellenthin M, Wagner J, DeBoer EM, Fink DS. Jet flow rate and needle position govern distal airway pressures during low-frequency jet ventilation. Laryngoscope Investig Otolaryngol 2021; 6:244-251. [PMID: 33869756 PMCID: PMC8035948 DOI: 10.1002/lio2.536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 12/02/2020] [Accepted: 01/27/2021] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVES Although jet ventilation is frequently used during surgery for airway stenosis, little is known about distal airway pressures during jet ventilation. The objective of the study is to determine how jet pressure, flow rate, and position of the ventilation needle relate to distal airway pressure magnitude and homogeneity. METHODS Two 3D models of the first five generations of the human airway tree were created. One is a duplicate of a human airway from a 15-year-old healthy male's computed tomography scan, and the other is an idealized symmetric model of human lung morphometry. Pressure transducers measured fifth-generation distal airway pressures in both models. A computer-controlled jet needle positioning system was used to ventilate the lung casts. The effects of jet needle position, jet pressure, and jet flow rate on distal airway pressure and homogeneity were measured. RESULTS Total entrained jet flow rate was the most reliable predictor of distal airway pressure. Pressure supplied to the jet ventilation needle had a positive linear relationship with distal airway pressure; however, this relationship was dependent on the jet needle flow resistance. As the ventilation needle moved closer to the tracheal wall, ventilation homogeneity decreased. Depth into the trachea was positively correlated with sensitivity of the needle to the tracheal wall. CONCLUSION In this model, total entrained jet flow rate is a more robust predictor of distal airway pressure than jet inlet pressure. More homogeneous ventilation was observed in our model with the ventilation needle centered in the proximal region of the trachea.
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Affiliation(s)
- Joshua Pertile
- Department of BioengineeringUniversity of Colorado DenverAnschutz Medical CampusAuroraColoradoUSA
| | - Bradford Smith
- Department of BioengineeringUniversity of Colorado DenverAnschutz Medical CampusAuroraColoradoUSA
- Department of Pediatrics, School of MedicineUniversity of ColoradoAuroraColoradoUSA
| | - Michelle Mellenthin
- Department of BioengineeringUniversity of Colorado DenverAnschutz Medical CampusAuroraColoradoUSA
- Department of Computer Science and EngineeringColorado Mesa UniversityGrand JunctionColoradoUSA
| | - Jennifer Wagner
- Department of BioengineeringUniversity of Colorado DenverAnschutz Medical CampusAuroraColoradoUSA
| | - Emily M. DeBoer
- Department of Pediatrics, School of MedicineUniversity of ColoradoAuroraColoradoUSA
| | - Daniel S. Fink
- Department of Otolaryngology, School of MedicineUniversity of ColoradoAuroraColoradoUSA
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26
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Laviola M, Niklas C, Das A, Bates DG, Hardman JG. Ventilation strategies for front of neck airway rescue: an in silico study. Br J Anaesth 2021; 126:1226-1236. [PMID: 33674075 DOI: 10.1016/j.bja.2021.01.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 01/06/2021] [Accepted: 01/18/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND During induction of general anaesthesia a 'cannot intubate, cannot oxygenate' (CICO) situation can arise, leading to severe hypoxaemia. Evidence is scarce to guide ventilation strategies for small-bore emergency front of neck airways that ensure effective oxygenation without risking lung damage and cardiovascular depression. METHODS Fifty virtual subjects were configured using a high-fidelity computational model of the cardiovascular and pulmonary systems. Each subject breathed 100% oxygen for 3 min and then became apnoeic, with an obstructed upper airway. When arterial haemoglobin oxygen saturation reached 40%, front of neck airway access was simulated with various configurations. We examined the effect of several ventilation strategies on re-oxygenation, pulmonary pressures, cardiovascular function, and oxygen delivery. RESULTS Re-oxygenation was achieved in all ventilation strategies. Smaller airway configurations led to dynamic hyperinflation for a wide range of ventilation strategies. This effect was absent in airways with larger internal diameter (≥3 mm). Intrapulmonary pressures increased quickly to supra-physiological values with the smallest airways, resulting in pronounced cardio-circulatory depression (cardiac output <3 L min-1 and mean arterial pressure <60 mm Hg), impeding oxygen delivery (<600 ml min-1). Limiting tidal volume (≤200 ml) and ventilatory frequency (≤8 bpm) for smaller diameter cannulas reduced dynamic hyperinflation and gas trapping, preventing cardiovascular depression. CONCLUSIONS Dynamic hyperinflation can be demonstrated for a wide range of front of neck airway cannulae when the upper airway is obstructed. When using small-bore cannulae in a CICO situation, ventilation strategies should be chosen that prevent gas trapping to prevent severe adverse events including cardio-circulatory depression.
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Affiliation(s)
- Marianna Laviola
- Anaesthesia and Critical Care, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK.
| | - Christian Niklas
- Anaesthesia and Critical Care, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK; Heidelberg University Hospital, Department of Anaesthesiology and Intensive Care, Heidelberg, Germany
| | - Anup Das
- School of Engineering, University of Warwick, Coventry, UK
| | - Declan G Bates
- School of Engineering, University of Warwick, Coventry, UK
| | - Jonathan G Hardman
- Anaesthesia and Critical Care, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK; Nottingham University Hospitals NHS Trust, Nottingham, UK
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Zha B, Wu Z, Xie P, Xiong H, Xu L, Wei H. Supraglottic jet oxygenation and ventilation reduces desaturation during bronchoscopy under moderate to deep sedation with propofol and remifentanil: A randomised controlled clinical trial. Eur J Anaesthesiol 2021; 38:294-301. [PMID: 33234777 PMCID: PMC7932749 DOI: 10.1097/eja.0000000000001401] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Hypoxaemia is frequently seen during flexible bronchoscopies that are done with a nasal approach under the traditional sedation with propofol. This study investigated the potential benefits of supraglottic jet oxygenation and ventilation (SJOV) using the Wei nasal jet tube (WNJ) in reducing hypoxaemia in patients undergoing bronchoscopy under moderate to deep intravenous sedation using a propofol, lidocaine and remifentanil cocktail. OBJECTIVES Our primary objective was to evaluate the efficacy and complications of SJOV via the WNJ during flexible bronchoscopy under moderate to heavy sedation with propofol and remifentanil. DESIGN A randomised controlled clinical trial. SETTING The 180th Hospital of People's Liberation Army, Quanzhou, China, from 1 June to 1 November 2019. PATIENTS A total of 280 patients aged ≥18 years with American Society of Anesthesiologists' physical status 1 to 3 undergoing flexible bronchoscopy were studied. INTERVENTIONS Patients were assigned randomly into one of two groups, a nasal cannula oxygenation (NCO) group (n = 140) using a nasal cannula to deliver oxygen (4 l min-1) or the SJOV group (n = 140) using a WNJ connected to a manual jet ventilator to provide SJOV at a driving pressure of 103 kPa, respiratory rate 20 min-1, FiO2 1.0 and inspiratory:expiratory (I:E) ratio 1:2. MAIN OUTCOME MEASURES The primary outcome was an incidence of desaturation (defined as SpO2 < 90%) during the procedure. Other adverse events related to the sedation or SJOV were also recorded. RESULTS Compared with the NCO group, the incidence of desaturation in the SJOV group was lower (NCO 37.0% vs. SJOV 13.1%) (P < 0.001). Patients in the SJOV group had a higher incidence of a dry mouth at 1 min (13.1% vs. 1.5%, P < 0.001) than at 30 min (1.5% vs. 0%, P = 0.159) or at 24 h (0% vs. 0%). There was no significant difference between the groups in respect of sore throat, subcutaneous emphysema or nasal bleeding. CONCLUSIONS SJOV via a WNJ during flexible bronchoscopy under moderate to deep sedation with propofol and remifentanil significantly reduces the incidence of desaturation when compared with regular oxygen supplementation via a nasal cannula. Patients in the SJOV group had an increased incidence of transient dry mouth. TRIAL REGISTRATION Registered at www.chictr.org.cn (ChiCTR1900023514).
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Affiliation(s)
- Benjun Zha
- From the Department of Anesthesiology, 180th Hospital of PLA, Quanzhou, China (BZ, ZW, PX, HX, LX) and Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA (HW)
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Leadership and teaching in airway management. Can J Anaesth 2021; 68:1317-1323. [PMID: 34231130 PMCID: PMC8260019 DOI: 10.1007/s12630-021-02057-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 04/01/2021] [Accepted: 04/01/2021] [Indexed: 01/15/2023] Open
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Abstract
Management of the unanticipated difficult airway is one of the most relevant and challenging crisis management scenarios encountered in clinical anesthesia practice. Several guidelines and approaches have been developed to assist clinicians in navigating this high-acuity scenario. In the most serious cases, the clinician may encounter a failed airway that results from failure to ventilate an anesthetized patient via facemask or supraglottic airway or intubate the patient with an endotracheal tube. This dreaded cannot intubate, cannot oxygenate situation necessitates emergency invasive access. This article reviews the incidence, management, and complications of the failed airway and training issues related to its management.
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Affiliation(s)
- Paul Potnuru
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.020, Houston, TX 77030, USA
| | - Carlos A Artime
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.020, Houston, TX 77030, USA
| | - Carin A Hagberg
- Anesthesiology, Critical Care & Pain Medicine, Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, 1400 Holcombe Boulevard, Unit 409, Houston, TX 77030, USA.
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30
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Lejus-Bourdeau C, Grillot N, Dupont S, Robert-Edan V, Bazin O, Viquesnel S, Pichenot V. Randomised comparison of Enk™ and Manujet™ for emergency tracheal oxygenation with a high-fidelity full-scale simulation. Anaesth Crit Care Pain Med 2020; 39:807-812. [PMID: 33039658 DOI: 10.1016/j.accpm.2020.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 01/03/2020] [Accepted: 01/23/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND We aimed to compare time and difficulties of emergency tracheal oxygenation with Enk™ or Manujet™ by anaesthesiologists or intensivists, in a full-scale cannot ventilate and intubate scenarios on a SimMan3G™ high-fidelity patient simulator. METHODS After ethical committee approval and written informed consent, teams (two to three learners with at least one physician senior) participating at a difficult airway training with a massive sublingual haematoma scenario, were randomised in Enk™ (E) group (29 teams, 76 learners) and Manujet™ (M) group (31 teams, 84 learners) according to the device at disposal. Main criterion was time between taking device in hand and first insufflation delay. Data were medians [25-75%]. RESULTS The handling-insufflation time was shorter with Enk™ than with Manujet™ (74 [54-87] seconds versus 95 [73-123] seconds (s), P=0.0112). The team number performing insufflation within one minute after device handling was higher in the E group (8, 27.6%) than in the M group (2, 6.4%) (P=0.0392) as well as the team number performing insufflation within 90s in the E group (22, 75.09%) than in the M group (12, 38.7%) (P=0.0047). In E group, 75% of learners reported no difficulty versus 58.8% in M group (P=0.0443). Insufflation frequency was high in both groups and higher than 12min-1 in 51.7% of the teams. CONCLUSION In a simulation context, Enk™ use is faster and easier. A high insufflation rate was also in favour of Enk™ that generates lower airway pressures.
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Affiliation(s)
- Corinne Lejus-Bourdeau
- Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu - Hôpital Mère Enfant, CHU Nantes, Place Alexis Ricordeau, F-44093 Nantes, France; Laboratoire Expérimental de Simulation de Médecine Intensive de l'Université (LE SiMU) de Nantes, 9, rue Bias, 44001 Nantes, France.
| | - Nicolas Grillot
- Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu - Hôpital Mère Enfant, CHU Nantes, Place Alexis Ricordeau, F-44093 Nantes, France; Laboratoire Expérimental de Simulation de Médecine Intensive de l'Université (LE SiMU) de Nantes, 9, rue Bias, 44001 Nantes, France
| | - Ségolène Dupont
- Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu - Hôpital Mère Enfant, CHU Nantes, Place Alexis Ricordeau, F-44093 Nantes, France; Laboratoire Expérimental de Simulation de Médecine Intensive de l'Université (LE SiMU) de Nantes, 9, rue Bias, 44001 Nantes, France
| | - Vincent Robert-Edan
- Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu - Hôpital Mère Enfant, CHU Nantes, Place Alexis Ricordeau, F-44093 Nantes, France; Laboratoire Expérimental de Simulation de Médecine Intensive de l'Université (LE SiMU) de Nantes, 9, rue Bias, 44001 Nantes, France
| | - Olivier Bazin
- Laboratoire Expérimental de Simulation de Médecine Intensive de l'Université (LE SiMU) de Nantes, 9, rue Bias, 44001 Nantes, France
| | - Simon Viquesnel
- Laboratoire Expérimental de Simulation de Médecine Intensive de l'Université (LE SiMU) de Nantes, 9, rue Bias, 44001 Nantes, France; Pôle Anesthésie Réanimation, CHU Rennes, 2, rue Henri Le Guilloux, 35033 Rennes cedex 9, France
| | - Vincent Pichenot
- Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu - Hôpital Mère Enfant, CHU Nantes, Place Alexis Ricordeau, F-44093 Nantes, France; Laboratoire Expérimental de Simulation de Médecine Intensive de l'Université (LE SiMU) de Nantes, 9, rue Bias, 44001 Nantes, France
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Heard A, Gordon H, Douglas S, Grainger N, Avis H, Vlaskovsky P, Toner A, Thomas B, Kennedy C, Perlman H, Fox J, Tarrant K, De Silva N, Eakins P, Patel P, Fitzpatrick S, Bright S, O'Keefe S, Do T, Staff V. Front-of-neck airway rescue with impalpable anatomy during a simulated cannot intubate, cannot oxygenate scenario: scalpel–finger–cannula versus scalpel–finger–bougie in a sheep model. Br J Anaesth 2020; 125:184-191. [DOI: 10.1016/j.bja.2020.04.067] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 03/19/2020] [Accepted: 04/07/2020] [Indexed: 12/20/2022] Open
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Smith C, McNarry AF. Airway Leads and Airway Response Teams: Improving Delivery of Safer Airway Management? CURRENT ANESTHESIOLOGY REPORTS 2020; 10:370-377. [PMID: 32837344 PMCID: PMC7369438 DOI: 10.1007/s40140-020-00404-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Purpose of Review Airway management remains a source of significant morbidity and mortality. This review considers recent summaries of complications and looks toward strategies to improve practice using a coordinated approach. Recent Findings A safety gap can exist between national recommendations and local practice. A lack of attention to end tidal carbon dioxide has repeatedly contributed to airway mismanagement. Clinicians must be trained in newer airway devices (videolaryngoscopes or supraglottic airways) to use them effectively. Time must be found to teach rarely performed skills (e.g., front-of-neck access). Both larger and smaller hospitals have benefitted from an airway lead or response team, coordinating education programs, ensuring the adoption of guidelines, standardizing equipment, and recognizing the role of human factors and ergonomics. Summary Even in the twenty-first century, the incidence of airway-related morbidity and mortality can be reduced, by an institutionally supported, coordinated approach to the whole process of airway care.
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Affiliation(s)
- Carolyn Smith
- South East Scotland School of Anaesthesia, St John’s Hospital, Livingston, EH54 6PP UK
| | - Alistair F. McNarry
- Department of Anaesthesia, Western General Hospital, NHS Lothian, Crewe Road South, Edinburgh, EH4 2XU UK
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Morrison S, Aerts S, Saldien V. The Ventrain Device: A Future Role in Difficult Airway Algorithms? A A Pract 2020; 13:362-365. [PMID: 31567271 DOI: 10.1213/xaa.0000000000001084] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The Ventrain is a small, manually operated, single-use, inspiratory flow-adjustable ventilation device that generates positive pressure during inspiration and, through a Bernoulli effect within the device, active suction during expiration. It was designed to provide emergency ventilation during airway obstruction via narrow-bore cannulae. The device has been used successfully in elective procedures lasting >1 hour. It remains to be seen if its theoretical advantages in "can't intubate, can't oxygenate" (CICO) scenarios translate to reliable clinical benefit and allow inclusion in future airway algorithms. We advocate for regular simulation training and the detailed reporting of clinical experience with this encouraging new tool.
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Affiliation(s)
- Stuart Morrison
- From the Department of Anesthesiology, Antwerp University Hospital, Edegem, Belgium
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Rehak A, Watterson LM. Institutional preparedness to prevent and manage anaesthesia‐related ‘can't intubate, can't oxygenate’ events in Australian and New Zealand teaching hospitals. Anaesthesia 2019; 75:767-774. [DOI: 10.1111/anae.14909] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2019] [Indexed: 12/15/2022]
Affiliation(s)
- A. Rehak
- Department of Anaesthesia Royal North Shore Hospital Sydney Australia
| | - L. M. Watterson
- Department of Anaesthesia Royal North Shore Hospital Sydney Australia
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Joffe AM, Aziz MF, Posner KL, Duggan LV, Mincer SL, Domino KB. Management of Difficult Tracheal Intubation: A Closed Claims Analysis. Anesthesiology 2019; 131:818-829. [PMID: 31584884 PMCID: PMC6779339 DOI: 10.1097/aln.0000000000002815] [Citation(s) in RCA: 127] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Difficult or failed intubation is a major contributor to morbidity for patients and liability for anesthesiologists. Updated difficult airway management guidelines and incorporation of new airway devices into practice may have affected patient outcomes. The authors therefore compared recent malpractice claims related to difficult tracheal intubation to older claims using the Anesthesia Closed Claims Project database. METHODS Claims with difficult tracheal intubation as the primary damaging event occurring in the years 2000 to 2012 (n = 102) were compared to difficult tracheal intubation claims from 1993 to 1999 (n = 93). Difficult intubation claims from 2000 to 2012 were evaluated for preoperative predictors and appropriateness of airway management. RESULTS Patients in 2000 to 2012 difficult intubation claims were sicker (78% American Society of Anesthesiologists [ASA] Physical Status III to V; n = 78 of 102) and had more emergency procedures (37%; n = 37 of 102) compared to patients in 1993 to 1999 claims (47% ASA Physical Status III to V; n = 36 of 93; P < 0.001 and 22% emergency; n = 19 of 93; P = 0.025). More difficult tracheal intubation events occurred in nonperioperative locations in 2000 to 2012 than 1993 to 1999 (23%; n = 23 of 102 vs. 10%; n = 10 of 93; P = 0.035). Outcomes differed between time periods (P < 0.001), with a higher proportion of death in 2000 to 2012 claims (73%; n = 74 of 102 vs. 42%; n = 39 of 93 in 1993 to 1999 claims; P < 0.001 adjusted for multiple testing). In 2000 to 2012 claims, preoperative predictors of difficult tracheal intubation were present in 76% (78 of 102). In the 97 claims with sufficient information for assessment, inappropriate airway management occurred in 73% (71 of 97; κ = 0.44 to 0.66). A "can't intubate, can't oxygenate" emergency occurred in 80 claims with delayed surgical airway in more than one third (39%; n = 31 of 80). CONCLUSIONS Outcomes remained poor in recent malpractice claims related to difficult tracheal intubation. Inadequate airway planning and judgment errors were contributors to patient harm. Our results emphasize the need to improve both practitioner skills and systems response when difficult or failed tracheal intubation is encountered.
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Affiliation(s)
- Aaron M. Joffe
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA; United States
| | - Michael F. Aziz
- Department of Anesthesiology & Perioperative Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Karen L. Posner
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA; United States
| | - Laura V. Duggan
- Department of Anesthesiology, Pharmacology, & Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Shawn L. Mincer
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA; United States
| | - Karen B. Domino
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA; United States
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Price TM, McCoy EP. Emergency front of neck access in airway management. BJA Educ 2019; 19:246-253. [PMID: 33456898 DOI: 10.1016/j.bjae.2019.04.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2019] [Indexed: 12/20/2022] Open
Affiliation(s)
- T M Price
- Royal Victoria Hospital, Belfast, UK
| | - E P McCoy
- Royal Victoria Hospital, Belfast, UK
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Rees KA, O'Halloran LJ, Wawryk JB, Gotmaker R, Cameron EK, Woonton HDJ. Time to oxygenation for cannula‐ and scalpel‐based techniques for emergency front‐of‐neck access: a wet lab simulation using an ovine model. Anaesthesia 2019; 74:1153-1157. [DOI: 10.1111/anae.14706] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2019] [Indexed: 11/30/2022]
Affiliation(s)
- K. A. Rees
- Department of Anaesthesia Monash Medical Centre Melbourne VIC Australia
| | - L. J. O'Halloran
- Department of Anaesthesia Monash Medical Centre Melbourne VIC Australia
| | - J. B. Wawryk
- Department of Anaesthesia Townsville Hospital Townsville QLD Australia
| | - R. Gotmaker
- Department of Anaesthesia St. Vincent's Hospital Melbourne VIC Australia
| | - E. K. Cameron
- Department of Anaesthesia Monash Medical Centre Melbourne VIC Australia
| | - H. D. J. Woonton
- Department of Anaesthesia Monash Medical Centre Melbourne VIC Australia
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38
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The MacGyver bias and attraction of homemade devices in healthcare. Can J Anaesth 2019; 66:757-761. [DOI: 10.1007/s12630-019-01361-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 03/11/2019] [Accepted: 03/19/2019] [Indexed: 10/27/2022] Open
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Fennessy P, Drew T, Husarova V, Duggan M, McCaul C. Emergency cricothyroidotomy: an observational study to estimate optimal incision position and length. Br J Anaesth 2019; 122:263-268. [DOI: 10.1016/j.bja.2018.10.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 09/18/2018] [Accepted: 10/02/2018] [Indexed: 10/27/2022] Open
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40
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Waberski AT, Espinel AG, Reddy SK. Anesthesia Safety in Otolaryngology. Otolaryngol Clin North Am 2019; 52:63-73. [DOI: 10.1016/j.otc.2018.08.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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41
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Qazi I, Mendonca C, Sajayan A, Boulton A, Ahmad I. Emergency front of neck airway: What do trainers in the UK teach? A national survey. J Anaesthesiol Clin Pharmacol 2019; 35:318-323. [PMID: 31543578 PMCID: PMC6748006 DOI: 10.4103/joacp.joacp_65_18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background and Aims: Front of neck airway (FONA) is the final step to deliver oxygen in the difficult airway management algorithms. The Difficult Airway Society 2015 guidelines have recommended a standardized scalpel cricothyroidotomy technique for an emergency FONA. There is a wide variability in the FONA techniques with disparate approaches and training. We conducted a national postal survey to evaluate current teaching, availability of equipment, experienced surgical help and prevalent attitudes in the face of a can’t intubate, can’t oxygenate situation. Material and Methods: The postal survey was addressed to airway leads across National Health Service hospitals in the United Kingdom (UK). In the anesthetic departments with no designated airway leads, the survey was addressed to the respective college tutors. A total of 259 survey questionnaires were posted. Results: We received 209 survey replies with an overall response rate of 81%. Although 75% of respondents preferred scalpel cricothyroidotomy, only 28% of the anesthetic departments considered in-house FONA training as mandatory for all grades of anesthetists. Scalpel-bougie-tube kits were available in 95% of the anesthetic departments, either solely or in combination with other FONA devices. Conclusion: The survey has demonstrated that a majority of the airway trainers in the UK would prefer scalpel cricothyroidotomy as emergency FONA. There is a significant variation and deficiency in the current levels of FONA training. Hence, it is important that emergency FONA training is standardized and imparted at a multidisciplinary level.
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Affiliation(s)
- Ilyas Qazi
- Department of Anaesthesia, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Cyprian Mendonca
- Department of Anaesthesia, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Achuthan Sajayan
- Department of Anaesthesia, Good Hope Hospital, University Hospitals Birmingham NHS Foundation Trust, Sutton Coldfield, UK
| | - Adam Boulton
- Department of Anaesthesia, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Imran Ahmad
- Department of Anaesthesia, Guy's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK
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Bouroche G, Motamed C, de Guibert J, Hartl D, Bourgain J. Rescue transtracheal jet ventilation during difficult intubation in patients with upper airway cancer. Anaesth Crit Care Pain Med 2018; 37:539-544. [DOI: 10.1016/j.accpm.2017.10.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 08/24/2017] [Accepted: 10/14/2017] [Indexed: 01/08/2023]
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43
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Onrubia X, Frova G, Sorbello M. Front of neck access to the airway: A narrative review. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2018. [DOI: 10.1016/j.tacc.2018.06.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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44
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Villiere S, Nakase K, Kollmar R, Arjomandi H, Lazar J, Sundaram K, Silverman JB, Lucchesi M, Wlody D, Stewart M. A Resuscitation Option for Upper Airway Occlusion Based on Bolus Transtracheal Lung Inflation. Laryngoscope Investig Otolaryngol 2018; 3:296-303. [PMID: 30186961 PMCID: PMC6119800 DOI: 10.1002/lio2.173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 04/12/2018] [Accepted: 04/23/2018] [Indexed: 11/11/2022] Open
Abstract
Background Acute laryngospasm sufficient to cause obstructive apnea is a medical emergency that can be difficult to manage within the very short time available for establishing an airway. We have presented substantial evidence that laryngospasm-based obstructive apnea is the cause of sudden death in epilepsy, and airway management is particularly challenging during seizure activity. Objective We sought to determine if the transtracheal delivery of a bolus of oxygen or room air below the level of an obstruction to inflate the lungs could be an effective method to prolong the time available for responders seeking to establish a stable airway, and, if so, what could be learned about optimization of delivery parameters from a rat model. Methods Rats were fitted with a t-shaped tracheal tube for controlling access to air and for measuring airway pressures. After respiratory arrest from simulated laryngospasm, bolus transtracheal lung inflation with a volume of gas equivalent to half the vital capacity was delivered to the closed respiratory system as the only resuscitation step. Results Bolus lung inflation was sufficient for resuscitation, improving cardiac function and re-establishing adequate oxygen status to support life. Inflation steps could be repeated and survival times were approximately 3 times that of non-inflated lungs. Conclusion The properties and consequences of bolus lung inflation are described as a foundation for procedures or devices that can be useful in cases of severe laryngospasm and other cases of upper airway obstruction. Level of Evidence 3.
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Affiliation(s)
- Sophia Villiere
- Department of Physiology and Pharmacology State University of New York Downstate Medical Center Brooklyn New York U.S.A.,Research Initiative for Scientific Enhancement (RISE) Program LIJMC, Department of Otolaryngology Suite 430, Lakeville Road New Hyde Park, NY US
| | - Ko Nakase
- Department of Physiology and Pharmacology State University of New York Downstate Medical Center Brooklyn New York U.S.A
| | - Richard Kollmar
- Department of Cell Biology State University of New York Downstate Medical Center Brooklyn New York U.S.A
| | - Hamid Arjomandi
- Department of Cell Biology State University of New York Downstate Medical Center Brooklyn New York U.S.A.,Department of Otolaryngology State University of New York Downstate Medical Center Brooklyn New York U.S.A
| | - Jason Lazar
- Department of Medicine State University of New York Downstate Medical Center Brooklyn New York U.S.A
| | - Krishnamurthi Sundaram
- Department of Otolaryngology State University of New York Downstate Medical Center Brooklyn New York U.S.A
| | - Joshua B Silverman
- Department of Otolaryngology State University of New York Downstate Medical Center Brooklyn New York U.S.A.,City University of New York Medgar Evers College Brooklyn New York U.S.A
| | - Michael Lucchesi
- Department of Emergency Medicine State University of New York Downstate Medical Center Brooklyn New York U.S.A
| | - David Wlody
- Department of Anesthesiology State University of New York Downstate Medical Center Brooklyn New York U.S.A
| | - Mark Stewart
- Department of Physiology and Pharmacology State University of New York Downstate Medical Center Brooklyn New York U.S.A.,Department of Neurology State University of New York Downstate Medical Center Brooklyn New York U.S.A
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45
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Affiliation(s)
- T Asai
- Department of Anesthesiology, Dokkyo Medical University Koshigaya Hospital, 2-1-50 Minamikoshigaya, Koshigaya, Saitama 343-8555, Japan
| | - E P O'Sullivan
- Department of Anaesthesia, St James's Hospital, Dublin, Ireland
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46
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Wexler S, Hall K, Chin RY, Prineas SN. Cannula cricothyroidotomy and rescue oxygenation with the Rapid-O2™ oxygen insufflation device in the management of a can't intubate/can't oxygenate scenario. Anaesth Intensive Care 2018; 46:97-101. [PMID: 29361262 DOI: 10.1177/0310057x1804600114] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We describe the successful use of cannula cricothyroidotomy and the Rapid-O2™ oxygen insufflation device (Meditech Systems Ltd, Dorset, UK) for rescue of a can't intubate/can't oxygenate (CICO) scenario in a patient with severe airway haemorrhage post-debridement of laryngeal amyloidosis. This case highlights the practical utility of a cannula technique for CICO rescue when appropriate equipment is used and when institutional measures are taken to prepare for this rare anaesthetic crisis.
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Affiliation(s)
| | | | - R Y Chin
- Head and Neck Surgeon, Otolaryngology Head and Neck Surgery, Nepean Hospital, Clinical Associate Professor, Clinical Director of Education Otolaryngology Head and Neck Surgery, The University of Sydney, Conjoint Associate, Western Sydney University, Sydney, New South Wales
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Duggan LV, Lockhart SL, Cook TM, O'Sullivan EP, Dare T, Baker PA. The Airway App: exploring the role of smartphone technology to capture emergency front-of-neck airway experiences internationally. Anaesthesia 2018. [DOI: 10.1111/anae.14247] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- L. V. Duggan
- Department of Anesthesiology, Pharmacology and Therapeutics; University of British Columbia; Vancouver Canada
| | - S. L. Lockhart
- Department of Anesthesiology, Pharmacology and Therapeutics; University of British Columbia; Vancouver Canada
| | - T. M. Cook
- Department of Anaesthesia; Royal United Hospitals Bath NHS Foundation Trust; Bath UK
| | - E. P. O'Sullivan
- Department of Anaesthetics; St. James's Hospital; Dublin Republic of Ireland
| | - T. Dare
- Department of Philosophy; Auckland University; Auckland New Zealand
| | - P. A. Baker
- Department of Paediatric Anaesthesia; Starship Children's Health; Auckland New Zealand
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48
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Brewster DJ, Nickson CP, Gatward JJ, Staples M, Hawker F. Should Ongoing Airway Education be a Mandatory Component of Continuing Professional Development for College of Intensive Care Medicine Fellows? Anaesth Intensive Care 2018. [DOI: 10.1177/0310057x1804600208] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
This study aimed to determine whether airway education should be introduced to the continuing professional development (CPD) program for College of Intensive Care Medicine (CICM) Fellows. A random representative sample of 11 tertiary intensive care units (ICUs) was chosen from the list of 56 units accredited for 12 or 24 months of CICM training. All specialist intensive care Fellows (n=140) currently practising at the eleven ICUs were sent the questionnaire via email. Questionnaire data collection and post-collection data analysis was used to determine basic respondent demographics, frequency of certain airway procedures in the past 12 months, confidence with advanced airway practices in ICU, participation in airway education in the past three years, knowledge of can't intubate, can't oxygenate (CICO) algorithms, preference for certain airway equipment/techniques, and support for required airway education as a component of the CICM CPD program. All responses were tabled for comparison. Data was analysed to establish any significant effect of another specialty qualification and current co-practice in anaesthesia on volume of practice, confidence with multiple airway procedures, use of airway equipment, and support for airway education. In total, 112 responses (response rate 80%) to the questionnaire were received within four weeks; 107 were completed in full (compliance 96%). All results were tabled. There is currently widespread support amongst CICM Fellows for airway skills education as a CPD requirement for CICM Fellows. Volumes of practice and confidence levels with different airway procedures vary amongst Fellows and further support the need for education.
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Affiliation(s)
- D. J. Brewster
- Director Medical Education and Clinical Dean, Consultant Intensivist, Cabrini Hospital; Clinical Dean, Central Clinical School, Monash University; Melbourne, Victoria
| | - C. P. Nickson
- Consultant Intensivist, Intensive Care Unit, Alfred Hospital; Adjunct Lecturer, Monash University; Melbourne, Victoria
| | - J. J. Gatward
- Consultant Intensivist, Intensive Care Unit, Royal North Shore Hospital; Clinical Lecturer, University of Sydney; Sydney, New South Wales
| | - M. Staples
- Biostatistician, Cabrini Institute, Cabrini Hospital; Department of Epidemiology and Preventive Medicine, Monash University; Melbourne, Victoria
| | - F. Hawker
- Chair Deteriorating Patient Committee, Intensive Care Unit, Cabrini Hospital; Director Professional Affairs, College of Intensive Care Medicine; Melbourne, Victoria
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50
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Cook TM. Strategies for the prevention of airway complications - a narrative review. Anaesthesia 2017; 73:93-111. [DOI: 10.1111/anae.14123] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2017] [Indexed: 12/17/2022]
Affiliation(s)
- T. M. Cook
- Anaesthesia and Intensive Care Medicine; Royal United Hospital; Bath UK
- School of Clinical Sciences; Bristol University; Bristol UK
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